Ethics and Deafness

Ethical Reasoning and Mental Health Services

with Deaf Clients
Virginia Gutman
Gallaudet University

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Ethical problems encountered by mental health practitioners Portability and Accountability Act of 1996 (HIPAA),
working with deaf clients are often complex and involve tort law, the Americans with Disabilities Act of 1990
issues not fully addressed in professional codes of ethics.
(ADA), and case law on a wide variety of topics related
A principles-based ethical reasoning process can assist in
resolving many of these ethical concerns. Principles such as to mental health practice. Although these professional
beneficence, nonmaleficence, autonomy, fairness, integrity, and legal foundations can be so broad and detailed as
and respect are found in the ethical codes of many sometimes to seem overwhelming, in practice they do
disciplines; these can also create a common language or not cover all situations. For example, the codes are
reference point when professionals from different fields
attempt to deal with shared problems. This article discusses
usually silent or vague about topics such as working
some applications of these principles in working with deaf with interpreters, language and communication issues,
individuals and proposes an ethical decision-making pro- accommodations, access to services, discrimination
cess that can provide a framework for ethical reasoning in faced by deaf professionals, and myriad other problems
thinking through complex problems.
commonly faced by mental health professionals
working with deaf people and the Deaf 2 community.
Mental health professionals1 are usually introduced to
Even topics that are explicitly covered in codes of
a code of ethics early in their professional training.
ethics or law, such as confidentiality or overlapping
Examples include the American Association for Marriage
relationships within the community, may have differ-
and Family Therapy (AAMFT, 2001) Code of Ethics;
ent implications for practitioners working with deaf
the American Counseling Association (ACA, n.d.)
people. For these reasons, code-based problem solving
Code of Ethics and Standards of Practice; the Code of
may not always suffice in addressing practical problems
Ethics of the American Psychological Association
encountered in mental health practice.3
(APA, 2002); the International Association of Marriage
Developing a systematic way of thinking through
and Family Counselors (IAMFC, n.d.) Ethical Stand-
ethical problems can assist practitioners in solving
ards; the Code of Ethics of the National Association of
problems that seem to be beyond the codes. The
Social Workers (NASW, 1999); and the Principles of
discussion here offers some methods and tools that can
Medical Ethics with Annotations Especially Applicable to
enhance the quality of ethical decisions in complex
Psychiatry (American Psychiatric Association, 2003).
and confusing situations and can also provide a way of
In addition to the professional codes of ethics,
supporting, justifying, and documenting decisions if
professionals in training must also learn fundamental
questions later arise.
legal requirements for professional practice found
in state practice regulations, the Health Insurance
Ethical Principles
Correspondence should be sent to Virginia Gutman, Department of
Psychology, Gallaudet University, 800 Florida Avenue NE, Washington,
It is possible to see all ethical codes as reflecting
DC 20002 (e-mail: virginia.gutman@gallaudet.edu). underlying ethical principles that are more general,

Journal of Deaf Studies and Deaf Education vol. 10 no. 2 doi:10.1093/deafed/eni017

Ó The Author 2005. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oupjournals.org
172 Journal of Deaf Studies and Deaf Education 10:2 Spring 2005
fundamental, and lasting than the specific behaviors
endorsed or prohibited by the codes. The various
mental health professions state the principles un-
derlying their codes of ethics in various terms. For
example, the NASW (1999) code lists ‘‘core values’’ of
service, social justice, dignity and worth of the person,
importance of human relationships, integrity, and
competence. The ACA (n.d.) code is based on the
principles of autonomy, nonmaleficence, beneficence,
justice, and fidelity (Herlihy & Corey, 1996). The
APA’s Ethical Principles (APA, 2002) lists the following:
‘‘beneficence and nonmaleficence, fidelity and respon-
sibility; integrity; justice; respect for people’s rights
and dignity’’ (p. 1). The American Psychiatric Associa-
tion’s discussion mentions competence, respect for
human dignity, compassion, professionalism, and
honesty, among other principles (American Psychiatric
Association, 2003). The Canadian Psychological Asso-
ciation (CPA, 2000) cites respect for individual dignity,
‘‘responsible caring,’’ social responsibility, and in-
tegrity. Beauchamp and Childress (2001) attempt to
summarize the most important underlying principles
in the many versions of biomedical ethics using five
categories: (a) respect for individuals’ autonomy; (b)
nonmaleficence; (c) beneficence; (d) justice; and (e)
maintaining a professional relationship, which includes
honesty, privacy, fidelity, and confidentiality. Self-care
is sometimes listed as an additional ethical principle.
Principles-based ethical reasoning can allow for
easier communication among different disciplines.
Their codes of ethics may differ, but the underlying
principles are likely to be similar. Implications of
several principles in working with deaf clients are
described in this article. After the principles are
described, some special applications in work with deaf
people are explored in more detail.
Nonmaleficence (‘‘do not harm’’) refers to all the
things a clinician may do to avoid injuring, distressing,
hurting, harming, or causing a negative outcome. The
opposite, beneficence (‘‘doing good’’) implies an obliga-
tion to provide services that are in the client’s best
interest and that are most likely to be helpful and to
lead to a good outcome. When deaf clients are
improperly diagnosed, inappropriately treated, or refused
needed treatment, these principles are violated. Many
treatments and services have the potential both to
harm and to help. A familiar example in the field of
deafness is the decision about cochlear implantation.
Clinicians must know a great deal about the probability
of benefit or harm in order to make ethical choices
when working with a client considering such a pro-
cedure (Christiansen & Leigh, 2002).
Clinicians also encounter issues of weighing potential
harm against potential benefit when asked to provide
services outside their areas of training. This may
happen frequently for clinicians in deafness, who may
be asked to help clients with an enormous range of
specialized problems. The potential for harm increases
when a clinician provides services in areas outside of
his or her training and experience; however, leaving the
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client untreated has potential for harm as well.
Autonomy or self-determination is an extremely
important consideration for clinicians and clients,
incorporating informed consent and lack of coercion.
Respecting a client’s autonomy can be unexpectedly
complicated. For example, a client cannot make a truly
autonomous choice without clear and accurate in-
formation. This means that the clinician must provide
honest information in a way that the client under-
stands, give the client an opportunity to express
a preference, and honor that preference. Autonomy
issues can be difficult if a client is very impulsive,
has poor judgment, or is easily intimidated. Further-
more, if a client has limited language skills or lacks
essential background knowledge, it may be difficult
even to explain clearly and fully what the choices are
(Glickman, 2003). Autonomous choice may be com-
promised even when a clinician tries to give the client
a choice. Some clients may be unaccustomed to
expressing their wishes. In the case of children or
cognitively impaired adults, parents or guardians may
have the legal right to consent to treatment. However,
this does not erase the clinician’s ethical responsibility
to respect the client’s autonomy (see the section on
autonomy and informed consent). Further complicat-
ing ethical decision making, ethical conflicts between
autonomy and beneficence can arise if a clinician’s
perception of what is best for the client conflicts with
the client’s wishes.
‘‘Justice’’ implies that professionals treat clients
fairly and do not engage in or support discriminatory
practices. We may encounter unjust practices when

agencies refuse to treat deaf patients, refuse to hire in-
terpreters or provide other needed accommodations, or
engage in stereotyping of deaf clients or professionals.
Issues of justice are also involved when managed care
organizations offer deaf clients a more limited range of
providers than hearing clients.
As an ethical principle, integrity requires clinicians
to be honest, providing accurate and unbiased in-
formation about any treatment options or professional
issues. Integrity also requires providing accurate
information about the clinician’s training, fees, and
policies. Although no one likes to be deceived, deaf
clients may particularly loathe hypocrisy and value
forthrightness. Within the Deaf community, the principle
of integrity may be doubly important for both its
ethical and cultural implications.
Fidelity (faithfulness and concern) is a hallmark of
the professional relationship. Clients place their trust
in mental health professionals with the expectation that
the clinician will conscientiously and carefully attend
to their well-being. This principle subsumes many
important ethical issues. Any exploitation of the client
violates this principle. Multiple relationships that
cause the clinician to lose focus on the client’s best
interest also indicate lack of fidelity. The professional’s
obligation to respect the client’s confidentiality and
privacy are also related to the duties of fidelity and care.
These issues are discussed further in the section on
application of ethical concerns with deaf clients.
Making self-care an ethical principle reflects the
insight that clinicians cannot provide good services
if they are overstressed, exhausted, ill, addicted, or
dealing with serious personal problems. Clinicians have
an ethical obligation to monitor their fitness to practice,
including judgment, decision making, problem solving,
and self-control. Clinicians with the skills to work with
deaf people are few and far between, and they may find
it difficult to slow down or say no when so many clients
are in need of their services. Considering self-care to be
an ethical principle may help clinicians feel more
justified in looking after their own well-being. Mental
health professionals sometimes have difficulty finding
methods of self-care that do not interfere with their
commitment to caring for their clients. Professionally
appropriate options include getting consultation
or supervision, limiting high-stress work activities
Ethical Reasoning 173
(with appropriate notice to clients and coverage of
professional responsibilities), personal therapy, train-
ing and professional development, personal wellness-
supporting activities (such as exercise, play, and
creative activities), and setting appropriate boundaries
to protect one’s personal life and privacy. However,
self-care activities can be difficult to initiate and
maintain for clinicians whose work and lives are in the
Deaf community and who may simultaneously feel
swamped and isolated.
Personal Characteristics and Skills
In addition to reflecting underlying principles, pro-
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fessional ethics can also be thought of in terms of the
qualities, skills, and character of individual professio-
nals. Beauchamp and Childress (2001) suggest that
certain ‘‘virtues’’ make ethical practice more likely.
Although there are many virtues that we hope our
caregivers have, Beauchamp and Childress especially
highlight compassion, judgment, insight, trustworthi-
ness, competence, conscientiousness, and integrity.
Without such traits, the mental health practitioner
has no moral compass for making ethical choices.
Kitchener (2000) additionally cites prudence, wisdom,
and respectfulness as important aspects of profes-
sionals’ character that facilitate ethical behavior.
Such qualities are difficult to teach (although
important for professional gatekeepers to consider) and
are thus often not directly addressed in professional
training. Professional competencies and skills, how-
ever, are receiving increasing emphasis. The Workgroup
on Ethics of the APA’s 2002 Competencies Conference
(Fuentes et al., 2002) identifies a number of ethical/
legal competencies that supplement knowledge of
codes, standards, guidelines, rules, and laws. These
include (a) the ability to recognize ethical issues in
varied contexts, (b) the ability to deal with conflict or
ambiguity in the codes, (c) the ability to apply ethical
knowledge in real-world situations, (d) the ability to
consult with others when necessary, (e) the ability to
confront and raise ethical issues in an appropriate
manner with other professionals, (f) the ability to adapt
one’s decision making when needed, (g) the ability to
participate in a peer network, and (h) self-awareness
and accurate self-assessment in ethical realms.
174 Journal of Deaf Studies and Deaf Education 10:2 Spring 2005

Ethical Reasoning 2003; McCrone, 2002; Raifman & Vernon, 1996).

However, even clinicians who specialize in working
Ethical reasoning starts with knowledge of a formal
with deaf clients face many ethical challenges. The
code of ethics, then incorporates other aspects of ethics
Deaf community is closely knit, so clinicians may find
to help clinicians solve ethical problems. Systematic
that maintaining confidentiality and avoiding multiple
ethical reasoning procedures endeavor to help profes-
relationships requires great delicacy and tact. Further-
sionals (a) understand their own value systems, (b)
more, due to being ‘‘the only game in town,’’ clinicians
recognize when an ethical problem exists, (c) analyze
may be asked to practice outside their area of competence
the problem carefully, (d) appropriately seek and use
or to assist agencies that do not provide equal access to
others’ advice and input, (e) identify the range of
services for deaf clients.
actions that might be taken, (f) weigh and choose
Additionally, all clinicians, whether their clients are
among the possible actions, and (g) evaluate the
deaf or hearing, must be guided both by professional
outcome. A principles-based or ethical reasoning
ethics and by law (including statutes, case law, and
approach asks the clinician to think ethically, rather
requirements of regulatory bodies). Sometimes these

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than simply following instructions (Ford, 2001; Lavin,
are in harmony but on some occasions, different
2003). Many issues that arise in working with deaf
sources may provide conflicting guidance (McCrone,
clients require both in-depth understanding of one’s
2002). Several ethically complicated problem areas are
professional code of ethics and excellent ethical
discussed next.
thinking. Ethical problems can take many forms
(Gutman, 2002). The following are a few.

 Different ethical principles may conflict. Competence

 The requirements of law, policy, or contracts
may conflict with ethical guidelines (McCrone, 2002).
 A clinician may want to comply with an ethical
requirement but may find it impractical or difficult.
 A particular problem may not be addressed in
the code of ethics at all.
 Two professionals may differ in their under-
standing of ethically appropriate behavior.
In general, mental health work with deaf people
involves the same ethical principles as work with
hearing clientele. However, ethical problems and potential
solutions may affect deaf clients differently than
hearing clients. Several ethical concerns that can have
special meaning or impact in treatment of deaf clients
will be discussed here.
Application of Ethical Concerns with
Deaf Clients
Mental health service agencies not familiar with deaf
individuals are at risk of making ethical as well as
clinical errors when confronted with a deaf client or
clinician. This can lead to substandard services, limited
choices, and lack of communication access (DeVinney,
Because so few mental health professionals are trained
to work with deaf people, questions related to a
clinician’s competence are frequently encountered.
These arise whenever clinicians must decide whether
to accept a deaf individual as a client or to whom to
refer a client needing more specialized services. In the
case of a deaf client, a clinician’s competence has many
aspects (Leigh, Corbett, Gutman, & Morere, 1996),
including:
 possessing appropriate clinical skills for working
with the client’s presenting problem;
 understanding enough about the developmental,
cultural, educational, social, emotional, cognitive,
linguistic, vocational, medical, and economic implica-
tions of deafness to place the client’s history and
concerns in appropriate context;
 being able to evaluate and adapt to the client’s
communication needs;
 knowing how to select and adapt treatment or
assessment techniques to match the client’s commu-
nication abilities and preferred language; and
 understanding enough about the client’s cul-
tural background and expectations to make sure that
treatment approaches are culturally appropriate.

Clinicians lacking in any of these skills might judge
their competencies to be inadequate for working with
a deaf client. They might risk actually harming the
client through inept service provision. Yet the ethical
codes of the mental health professions mandate that
clinicians should achieve competence in working with
diverse clients, including those with disabilities, and
should not make clinical decisions in a discriminatory
way. Additionally, the ADA requires that services be
accessible. Furthermore, it is sometimes the case that
no other clinician or agency is able to provide better
service to the client.
Thinking about the principles involved can help
identify possible solutions. The principles of benefi-
cence, nonmaleficence, and faithfulness require that
clinicians provide only services that they are competent
to provide. If clinicians provide services outside their
areas of competence, they risk both failing to help the
client and actually harming the client. However, if the
clinician rejects the client for treatment without
providing a better option, the client could be doubly
harmed: demoralized and discouraged at the rejection,
and still left with the original problem untreated.
Consideration of these principles suggests approaches
that might include the following:
 to accept the case but to ‘‘play catch-up’’ to get
the information, training, consultation or supervision
that is lacking (addressing concerns about helping and
not harming the client—the clinician becomes com-
petent to provide a helpful service);
 to assist the client in advocating with another,
better qualified service or agency to provide appro-
priate treatment to the client (again, helping and not
harming—the client receives a helpful service);
 to work within one’s own agency in obtaining
resources to hire qualified clinicians and/or inter-
preters to serve the client (helping and justice—
advocating to provide fair treatment for the client so
that beneficial services can be provided to this client
and perhaps to others with similar needs);
 to advocate with third-party payers to allow
clients to be seen by the most qualified service
provider, even if this is outside the provider’s usual
network or panel (again, this addresses the principles
of helping and justice); and
Ethical Reasoning 175
 to collaborate with another clinician or agency
to provide service as a team (beneficence and non-
maleficence are enhanced—collaboration maximizes
potential benefit and reduces the chance of harm).
The principles of autonomy and integrity further
suggest that professionals must accurately disclose the
limits of their competence to clients and allow the
client to determine whether to engage in mental
health treatment or assessment (unless the treatment or
evaluation is court-ordered). Thus, whatever option
the clinician pursues, an ethical clinician must make
sure the client is informed about treatment possibilities
and choices, and is involved in all treatment decisions.
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A meaningful informed consent procedure must
take into account the client’s language, vulnerability,
sophistication, and understanding of mental health
services (Glickman, 2003).
Communication Access
Communication is such an important aspect of
competence in working with deaf clients that it
deserves special focus. Deaf clients typically view clear
communication (and a concomitant positive attitude
toward deaf people) as key characteristics of a compe-
tent service provider. However, communication com-
petence requires investments of time and money.
Agencies and individual clinicians sometimes try to
avoid costs such as interpreters’ fees by either declin-
ing to serve deaf clients or by providing services that
are substandard because of lack of communication.
In some instances, programs do not understand either
the mechanics or the ethics of working with an
interpreter and refuse to serve deaf clients based on
this misunderstanding.
However, the ethical principle of justice and
legislation such as the ADA require that services
offered to the general population be accessible to deaf
individuals as well. Several cases have clarified the
ADA requirements. Courts have required mental
health service agencies to provide qualified interpreters
(DeVinney, 2003), to hire clinicians who are fluent
in sign language (Raifman & Vernon, 1996; Tugg v
Towey, 1994), and to provide appropriate technology
for clients to communicate with service providers.
The ADA does not require agencies to provide
176 Journal of Deaf Studies and Deaf Education 10:2 Spring 2005
accommodations that are an ‘‘undue burden.’’ How-
ever, in assessing burden, courts consider all the
resources available to the larger system of which
a service, clinic, or agency is a part.
Mental health services cannot be provided without
communication. Not all clients with hearing loss have
the same communication needs, skills, or preferences.
Some require a sign language interpreter for adequate
communication. Others may want a deaf clinician or
a Certified Deaf Interpreter. Some clients prefer oral
communication or writing back and forth (either on
paper or on a computer). Thus, the first issue in
providing communication access is assessing the
client’s needs and preferences. The ethical principles
of fairness and respect for the individual’s wishes and
choices are key in determining whether communication
is adequate.
Confidentiality
Confidentiality is of major importance in mental health
services and can be especially meaningful for deaf clients.
The Deaf community shares some characteristics of
rural communities, ethnic communities, and other
small, tightly knit groups that can make privacy
difficult to maintain (Gutman, 2002). First, people
know each other within the community—there is little
anonymity. Second, people notice and are interested in
what others do. Third, individuals and families know
one another over long periods of time, keeping contact
from childhood through old age, so events of childhood
or youth are remembered within the community
throughout one’s life. Fourth, information and news
about community members is shared rapidly. Even
before the advent of instant messaging, deaf people in
California often knew within hours of a problem
experienced by a deaf family in New York. This can
lead to quick community support in times of need, but
it also makes it difficult to keep problems private. In
fact, the norms of the Deaf community may favor
sharing information and providing support, and
withholding information can be interpreted as snob-
bery or lack of trust in the community.
In addition to the community issues mentioned
above, many deaf people have had the experience of
hearing people sharing information with each other but
refusing to tell the deaf individual what is going on.
This happens at the family dinner table as well as in
professional contexts. Furthermore, many deaf people
can remember a professional—perhaps a counselor,
teacher, or supervisor—who told their parents or co-
workers information that was meant to be confidential.
All this can lead to a lowered expectation of privacy and
difficulty trusting a clinician to keep information
confidential.
Every ethical principle points to the importance
of maintaining confidentiality. Violations of confiden-
tiality may harm a client’s reputation or self-respect.
Integrity requires the clinician to follow through on the
implicit and explicit promises of confidentiality made
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to clients. Yet there are times when confidentiality
cannot be preserved, such as when the client is a danger
to self or others (the limits to confidentiality are spelled
out in state and federal law). Respect for the client’s
autonomy requires that clients know from the outset
the limits of confidentiality. All ethical and legal
standards require the clinician to be knowledgeable
about when confidentiality will be upheld and when it
will not, and to make sure that the client has accurate
information. Among the confidentiality issues that
could be discussed between clinician and client are (a)
how to reduce the chances that the client will be seen
by acquaintances when arriving for or leaving from
appointments, (b) how the client or the clinician will
avoid or respond to prying questions, and (c) how to
behave if the client and clinician run into each other in
a public setting (Leigh, 2002; Leigh & Lewis, 1999).
Clinicians also need to consider how they will
handle information about clients that may be offered
by third parties. Concerned friends of the client may
approach the clinician at a social event to describe
‘‘what’s really going on.’’ Other professionals, such as
teachers or vocational trainers, may feel some re-
sponsibility for the client and want to share in-
formation. Clinicians must decide how they will
respond to such overtures, remembering that partici-
pating in a conversation about a client may be perceived
as a violation of confidentiality, even if the clinician
does not provide any information or acknowledge that
the therapeutic relationship exists.
Similarly, two hearing clinicians seen talking at any
length in a public place, such as an agency hallway, may

be assumed by onlookers to be discussing a client, even
if that is not the topic of their conversation. Obviously,
confidential information should not be discussed in
public, even if the clinician believes bystanders will not
hear the conversation. Beyond this, many clinicians
who work with deaf clients believe that it is ethically
appropriate to sign during all conversations that take
place in public view, so as to avoid any misunderstand-
ing. This promotes ethical principles of fidelity and
trustworthiness in professional relationships.
Multiple Relationships
Overlapping relationships present constant ethical
challenges to mental health professionals working with
deaf people, especially those providing services within
the Deaf community (Corbett, 2002; Guthmann &
Sandberg, 2002; Gutman, 2002; Leigh, 2002). It is
common for individuals within the community to have
several social and professional relationships. A teacher
may also be an interpreter; a clinician may also be
a consultant to a vocational training program; a client’s
parents might be close friends with a clinician’s office
mate; a clinician’s daughter and a client’s son may
attend the same school. Because multiple overlapping
relationships are ubiquitous, their risks for clients and
therapists can easily be overlooked or dismissed. It is
true that some types of multiple relationships are
considered to be benign and would not be expected to
compromise a client’s services (Faulkner & Faulkner,
1997; Gutheil & Gabbard, 1993; Guthmann & Sandberg,
2002). However, there are ethical risks involved,
specifically, the risk of the overlapping relationships
causing harm to the client by reducing the clinician’s
objectivity, exploiting the client, compromising confi-
dentiality, creating a conflict of interest, or decreasing
the effectiveness of treatment (Kitchener, 2000; Schank,
Slater, Banerjee-Stevens, & Skovholt, 2003).
One way of looking at multiple relationships is in
terms of personal and professional boundaries. A range
of approaches to boundary issues in treating deaf
clients has been suggested (Peoples, 2002; Guthmann &
Sandberg, 2002). Several issues can make boundary
management difficult. First, members of the commu-
nity may be used to overlapping relationships in other
spheres of personal and business life, and may even
Ethical Reasoning 177
expect them. A satisfied client—deaf or hearing–may
naturally want to refer friends and family members to
the therapist. However, treating clients who are closely
related or involved with other clients has a high risk of
compromising a counselor’s objectivity. A similar issue
arises when a client turns out to have ties to people
in the therapist’s personal or professional life. This
may threaten confidentiality, compromise services, and
create conflicts of interest for the therapist. Deaf
therapists may often be faced with the expectation that
they will engage in multiple overlapping relationships,
especially if they participate as active and respected
community members (Leigh, 2002; Leigh & Lewis,
1999; Lytle & Lewis, 1996). Because overlapping
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relationships can blur the boundary between personal
and professional lives, they can be difficult to analyze
dispassionately. Consultation with a supervisor or trusted
colleague is especially helpful in assessing potential
risks. Questions to address include: (a) Does the
multiple relationship create a role conflict for clinician
or client? (b) Does the multiple relationship threaten
confidentiality? and (c) Which relationship will be
primary?
Autonomy and Informed Consent
A number of issues may compromise the autonomy of
deaf individuals receiving mental health services. In the
past, mental health providers have sometimes made
treatment or assessment decisions ‘‘behind the back’’ of
the deaf consumer. Further, information has been
shared with hearing friends or relatives without the
deaf individual giving appropriate permission (Glickman,
2003; Lane, 1992; Sussman & Brauer, 1999). The
standard of care in health care today demands that
clients be given the opportunity to choose whether to
participate in treatment. Even if the client is a minor or
not competent, assent is usually required. Several
issues can interfere with a deaf client’s making a truly
informed and autonomous choice about treatment.
First, some professionals may lack the communication
competence necessary to explain clearly the nature of
treatment and the options available. In such a case,
involvement of interpreters or communication special-
ists may be necessary to make the information provided
clear and meaningful. Some deaf clients, however, may
178 Journal of Deaf Studies and Deaf Education 10:2 Spring 2005
be unsophisticated about treatment options and may
not understand treatment options even when they are
explained by an expert skilled in communicating with
individuals who do not use standard sign systems. The
client may not even understand that he or she has
a choice, or may be so used to others making decisions
that refusal would seem impossible. In such situations,
the client’s consent or assent to treatment would lack
real autonomy. One way to promote more autono-
mous decision making about treatment is to provide a
pretreatment phase to educate the client about
these matters so that true choice becomes possible
(Glickman, 2003).
A second impediment to client autonomy occurs
when a clinician intentionally or unintentionally slants
the information given to the client so as to support the
clinician’s own beliefs and opinions. Clients can make
informed, autonomous decisions only if they have
appropriate unbiased information. Mental health
professionals who work with deaf people are likely to
have personal and professional opinions about issues
such as educational approaches, cultural identity, and
cochlear implantation. Staying up to date on the best
professional literature on all sides of such issues should
be regarded as an ethical obligation (Pollard, 2002).
Work with Children and Families
Practitioners may be asked to work with families, often
including both deaf and hearing members. Ethical
principles become more complicated when working
with a family because the potential benefits and harm
to several people at once must be considered (Thorp &
Fruzzetti, 2003). Competence issues are enlarged
because the clinician must understand family dynamics
and child development as well as the professional and
deafness-related skills mentioned earlier (Brice, 2002).
Confidentiality becomes more complicated because
parents may have the right to know what transpires in
their child’s therapy, yet the child’s privacy is also
important (Richards, 2003). Autonomy issues are more
complicated if different family members have different
preferences about communication or treatment. In
addition, family treatment may often involve the ‘‘hot-
button’’ issues mentioned above, such as cochlear
implantation, language interventions, or educational
choices (Pollard, 2002). One of the clinician’s obliga-
tions is to help parents get accurate and unbiased
information, even though the clinician may have strong
personal beliefs about particular interventions and
approaches (Christiansen & Leigh, 2002).
Communication difficulties or conflicts within
families can produce special ethical challenges (Harvey,
2002). For example, communication between deaf and
hearing family members may be limited, yet some
family members may resist using interpreters for
family sessions. The principles of justice and helpful-
ness dictate that all family members should have equal
access to treatment in a family therapy session. At the
same time, the principle of autonomy endorses
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respecting clients’ wishes. What if the communication
method requested by one family member conflicts with
the wishes or needs of another member of the family?
In family therapy, the therapist has an ethical obligation
to each member of the family and to the family system
as a whole (Huber, 2001; IAMFC, n.d.). Obtaining
individual informed consent from each family member,
including assent from the children (AAMFT, 2001;
Ford, 2001), is one way to give each individual an
opportunity to shape how the therapy will be conducted,
including the type of communication to be used.
Ethical Problem Solving
With complex issues such as those discussed above,
clinicians may not be able to get clear guidance from
their profession’s code of ethics. All professional codes
of ethics have limitations (Ford, 2001; McCrone,
2002). They always represent compromise consensus
statements and are of necessity vague and general.
They may be difficult to apply to specific situations and
can produce dilemmas in which two or more principles
or standards appear to conflict. Some problems may
not be addressed in the code at all. Sometimes, more
than one code of ethics may be involved and require
different behaviors (for example, if the clinician
unexpectedly finds him- or herself in more than one
role, such as interpreter and therapist). In some
situations, legal requirements may conflict with a code
of ethics.
At such times, the clinician needs not only
a thorough familiarity with the code of ethics and

its underlying principles but also a decision-making
process to follow. An ethical decision-making model
can provide a framework for ethical practice in
situations where the code does not provide enough
specific guidance. Several decision-making models or
procedures have been suggested (e.g., CPA, 2000;
Ford, 2001; Gutman, 2002; Haas & Maloof, 2002; Hill,
Glaser & Hardin, 1995; Joseph & Conrad, 1995;
Kitchener, 2000; Koocher & Keith-Spiegel, 1998;
Welfel & Kitchener, 1992; Zitter, 1996). The model
suggested in this section gives the service provider
a method for considering ethical dilemmas or conflicts
in a consistent, systematic, and thorough way; taking
specific steps to resolve the problem; and documenting
careful decision making in case of a later complaint.
Suggested steps in ethical problem solving are de-
lineated next, followed by an example of how they
might be used to assist in resolving an ethical problem.
Step 1. Recognize that an ethical issue exists. This
recognition may arise from knowledge of the ethical codes,
conversations and feedback from colleagues and super-
visors, client reactions, or a hard-to-define sense that
‘‘something’s not right.’’
Step 2. Define the ethical issue. What does the code
of ethics say? Do two contradictory actions both seem
to be required? Is the clinician being asked to do
something that is contrary to an ethical standard? Does
the clinician have obligations to several parties whose
rights or needs may conflict? Do legal or administrative
requirements seem to contradict ethical mandates?
Does the course of action that seems ethically appropriate
appear to be impractical, undesirable, or unfeasible?
Step 3. Consider the ethical principles that are
involved. Is the client at risk of harm? Is the client
likely to benefit? Is the clinician acting honestly? Is the
clinician being trustworthy and conscientious? Is the
client being treated fairly? Are the client’s wishes and
decisions respected?
Step 4. Consult with colleagues. Get feedback on
what ethical issues are involved. Make notes of the
consultations, including dates and the advice received.
Step 5. Generate possible solutions. Sometimes
a dilemma can be resolved by forcing oneself to create
three or more possibilities. This helps to make the
problem-solving process more creative and open. Even
if some of these seem far-fetched or impractical, they
Ethical Reasoning 179
may contain the germ of a good idea. Continued
consultation with colleagues can lead to additional
ideas.
Step 6. Analyze each of the possible courses of action
envisioned in Step 5. What outcomes would be
expected of each? What benefits or harms might
occur? Is there a way to combine several of the
possibilities so as to maximize the benefits and
minimize the risks?
Step 7. Based on the analysis of expected outcomes,
choose a course of action. Additional consultation may
be helpful in planning how to carry out the selected
plan. Make notes about what was considered and why
each possibility was selected or rejected.
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Step 8. Implement the plan and observe the results.
Step 9. Evaluate the success of the action taken. Did
it benefit the client? Did it cause anyone harm? Was it
honest? Did it enhance the client’s autonomy? Did it
seem fair to all concerned? Does it satisfy the clinician’s
values? Get feedback about the result from colleagues or
supervisors.
Step 10. Revise the plan, if necessary, based on this
evaluation.
Step 11. Make sure that every step of the decision-
making process is adequately documented and placed
in the client’s chart or record. The dates of all contacts,
consultations, and decisions should be included, as well
as identification of all consultants or supervisors.
Sample Case
A graduate student, whom we will call Evelyn,4
attended a state school for the Deaf with about 85
students and had an excellent relationship with her
high school English teacher, Mrs. Smith, who was also
her homeroom teacher and class advisor. Mrs. Smith
encouraged the students to write about their lives and
experiences, and Evelyn shared much of herself in her
writing. She started a journal in which she wrote about
her own fears and dreams, conflicts with her mother,
and relationships with friends and boyfriend. She often
let Mrs. Smith read what she had written because she
trusted her. Mrs. Smith committed a lot of time and
energy to encouraging her best students, including
Evelyn, to work to their potential and to go to college,
and Evelyn continues to be grateful for her help.
Currently, they exchange occasional e-mail and holiday
180 Journal of Deaf Studies and Deaf Education 10:2 Spring 2005
greetings, even though they haven’t seen each other for
about 5 years. Evelyn still has several close friends from
high school, and they get together several times a year
and love to reminisce about their time together in high
school.
Evelyn graduated from high school and college,
then entered graduate school in one of the mental
health professions. She is currently doing an internship
back in her home state, in which she helps to run
a group with deaf children who have been abused. One
day Evelyn’s supervisor introduced her to a new child
in the group, and Evelyn was stunned to learn that this
4-year-old is Mrs. Smith’s adopted daughter. The little
girl had been abused by her birth parents, and at the
age of two was taken away from her birth mother and
placed in foster care, then later adopted by the Smiths.
Evelyn is unsure what to do. Is it okay for her to
work with Mrs. Smith’s daughter? Should she say
something to Mrs. Smith about it? Should she tell her
supervisor she has a conflict of interest? What if her
supervisor asks her to do a family interview? What if
her friends start talking about Mrs. Smith the next
time they get together? Here is how she might walk
through a decision-making process for this ethical
problem.
Step 1. Does an ethical issue exist? Evelyn knows that
her discipline’s code of ethics warns that multiple
relationships can be risky. She feels uncomfortable at
the idea of changing her relationship with Mrs. Smith.
How could she possibly presume to give parenting
advice to Mrs. Smith? At the same time, she feels she
owes Mrs. Smith and would like to help her family.
Evelyn has lost sleep over this situation. Her
discomfort tells her an ethical issue may exist.
Step 2. Define the ethical issue. Evelyn is concerned
about having a prior personal relationship with a client.
She is not sure whether she can be objective, and if she
were required to give negative feedback to Mrs. Smith,
she is not sure she could do it. In addition, Mrs. Smith
has always been the one to advise and encourage
Evelyn. It would be hard for Evelyn to switch roles and
give advice or counsel to Mrs. Smith.
Step 3. Consider the ethical principles that are
involved. If Evelyn cannot be objective about this
family, the family may not get the best care. In
addition, Evelyn may learn information about the
family that she cannot share with her close friends, who
are also close to Mrs. Smith. On the other hand, Mrs.
Smith’s family needs services, and Evelyn does not
want to be the reason that their child is not getting
help. Evelyn is not sure that Mrs. Smith realizes that
Evelyn now works at this agency and does not know
whether Mrs. Smith realized when she requested
services that Evelyn, a former student, might have
access to personal information about her. There are
multiple ethical principles involved, including benef-
icence, fidelity (confidentiality, multiple relationships),
and justice.
Step 4. Consult with colleagues. Luckily for Evelyn,
she has several supervisors in the agency. She
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hesitantly brings the issue up with the supervisor with
whom she feels most comfortable. They discuss
Evelyn’s past and current relationship with the Smith
family. Evelyn makes a note about this discussion and
includes it in the Smith family’s file. The note says that
Evelyn and Dr. Jones discussed issues related to a prior
relationship between Evelyn and the Smith family, and
gives the date it was discussed. Both Evelyn and the
supervisor sign the note.
Step 5. Generate possible solutions. After they have
identified the issues and possible problems, Evelyn and
Dr. Jones brainstorm possible actions. One possibility
is for Evelyn to switch to a different rotation so that she
will not need to work with the Smith family. Another is
for the Smiths to be referred to another agency. Still
another is for Evelyn to work with the Smith family as
she does with the others who are referred to her unit. It
might also be possible for another intern to work with
the Smiths while Evelyn works with other children and
families. They also talk about the possibility of
discussing the situation with the Smiths to see what
they prefer.
Step 6. Analyze each of the possible courses of action
envisioned in Step 5. Dr. Jones and Evelyn want to
think about the possibilities. They schedule a second
meeting to think about what would have the least risks
to the Smiths and the most potential benefit. Both Dr.
Jones and Evelyn agree that Evelyn working with the
Smiths has a risk of causing some serious problems in
their treatment. It also risks damaging Evelyn’s
relationship with Mrs. Smith, which she very much
values. Furthermore, it might make Evelyn’s interactions

with her friends difficult, because they are likely to
bring up Mrs. Smith in their casual conversation. They
discuss how to get treatment for the Smiths without
involving Evelyn. They discuss how to respect the
Smith’s autonomy and privacy.
Step 7. Based on the analysis of expected out-
comes, they choose a course of action. Evelyn and
Dr. Jones decide that three possibilities are feasible,
ethically appropriate, and would afford the Smiths
access to services. They decide that Dr. Jones will
meet with the Smiths and explain these three
treatment options. Their first option is to place
their daughter in the group. If they do that, Evelyn
will not work directly with their daughter, but they
may see her in the room working with other
children. The Smith’s family situation will not be
discussed at any meeting where Evelyn is present.
However, Evelyn might have casual interaction with
the Smith’s daughter, such as helping the children
to line up for a fire drill or monitoring a group
activity. A second option is for the Smith family to
receive individual and family therapy from senior
staff of the agency but not to have their daughter in
the group. A third option is to refer them to another
agency.
Evelyn’s agency provides the most deaf-culturally
sensitive services in the area. If the Smiths receive
services at another agency, they will have less deaf-
friendly services but more privacy. Dr. Jones and
Evelyn agree that they want the Smiths to have the
opportunity to decide which of these values are more
important to them. Evelyn writes a note for the file,
summarizing the options that they considered and why
they selected this approach. She and Dr. Jones both
sign the note.
Step 8. Implement the plan and observe the results.
Dr. Jones met with the Smiths. They chose to have
individual and family therapy but not to have their
daughter in the group. Mr. and Mrs. Smith gave Dr.
Jones permission to explain this to Evelyn.
Step 9. Evaluate the success of the action taken. Dr.
Jones and Evelyn met to review the decision and to let
Evelyn know what the Smiths decided. At their first
family therapy session, the family therapist checked
with the family to see whether they still felt comfort-
able with their decision.
Ethical Reasoning 181
Step 10. Revise the plan, if necessary, based on this
evaluation. The family therapist will take the re-
sponsibility of continuing to monitor how this is
working out. Having taken over the case, he or she will
be responsible for further treatment recommendations.
Step 11. Make sure that every step of the decision-
making process is adequately documented and placed
in the client’s chart or record. Dr. Jones and Evelyn
carefully reviewed the file before they turned the case
over to the family therapist to make sure that all their
discussions were accurately noted, dated, and signed.
This decision-making process allowed Evelyn to
resolve a difficult and sensitive issue and to do so in
a collaborative way so that she did not feel alone or ‘‘out
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on a limb.’’ It allowed her to come to a decision that
respected her needs as well as the needs of the client
and to make sure that she had the support of her
agency in doing so.
Conclusion
A principles-based ethical decision-making process can
help mental health professionals deal with ethical
problems or issues that are not adequately dealt with in
the codes. Clinical work with deaf individuals requires
creativity and flexible thinking, and may pose some
special ethical challenges for clinicians. Because the
principles underlying the various codes of ethics in the
mental health professionals are similar, use of prin-
ciples-based ethics can facilitate communication in
multidisciplinary teams. A principles-based approach
to ethics can also assist with creative problem solving
when faced with ethical dilemmas.
Familiarity with a professional code of ethics,
ethical principles, and relevant state and federal laws
(such as the ADA) provides an important foundation
for all ethical decisions. In situations where the codes
and laws do not provide clear guidance, use of a
systematic ethical decision-making process such as the
one described here can lead to good and defensible
solutions to ethical problems.
For clinicians at any level of experience, consulta-
tion with colleagues and supervisors knowledgeable
about work with deaf clients is essential to provide
high-quality services and to deal with ethical chal-
lenges as they arise.
182 Journal of Deaf Studies and Deaf Education 10:2 Spring 2005
Notes
1. The terms clinician, professional, or mental health pro-
fessional are used to refer to practitioners in any mental health
discipline, such as counseling, psychology, psychiatry, social
work, or marriage and family therapy.
2. In this article, the convention of capitalizing the word
deaf to indicate affiliation with the Deaf culture and community
is followed. Use of the lowercase simply indicates an audiological
condition of hearing loss.
3. This discussion does not provide legal guidance or
consultation on specific cases. If such assistance is needed, an
attorney experienced in mental health law or the ethics
committee of the relevant professional association could be
consulted.
4. This case, including all names and situations, is fictitious.
References
American Association for Marriage and Family Therapy (2001)
AAMFT code of ethics, effective July, 1, 2001. Retrieved
December 12, 2003, from www.aamft.org.
American Counseling Association (n.d.). ACA code of ethics and
standards of practice. Retrieved December 9, 2003, from
www.counseling.org.
American Psychiatric Association (2003). The principles of
medical thics with annotations especially applicable to psychiatry
(2001 ed., including 2003 Amendments). Washington, DC:
Author.
American Psychological Association (2002). Ethical principles of
psychologists and code of conduct. American Psychologist,
57, 1060–1073.
Beauchamp, T., & Childress, J. (2001). Principles of biomedical
ethics (5th ed.). New York: Oxford University Press.
Brice, P. (2002). Ethical issues in working with Deaf children,
adolescents, and their families. In V. Gutman (Ed.), Ethics in
mental health and deafness (pp. 52–67). Washington, DC:
Gallaudet Press.
Canadian Psychological Association (2000). Canadian code of
ethics for sychologists (2nd ed.) Retrieved August 20, 2004,
from http://www.cpa.ca/ethics2000.html.
Christiansen, J., & Leigh, I. (2002). Cochlear implants in children:
Ethics and choices. Washington, DC: Gallaudet Press.
Corbett, C. (2002). Ethical issues when working with minority
deaf populations. In V. Gutman (Ed.), Ethics in mental health
and deafness (pp. 84–98). Washington DC: Gallaudet Press.
DeVinney, J. (2003). Prologue: My story. In N. Glickman, &
S. Gulati (Eds.), Mental health care of deaf people: A
culturally affirmative approach (pp. xxi–xxxvi). Mahwah, NJ:
Lawrence Erlbaum.
Faulkner, K., & Faulkner, T. (1997). Managing multiple
relationships in rural communities: Neutrality and boundary
violations. Clinical Psychology: Science and Practice, 4,
225–234.
Ford, G. (2001). Ethical reasoning in the mental health professions.
Boca Raton: CRC Press.
Fuentes, C., Yarrow, C., Willmuth, M., Constantine, M.,
Hansen, N., & Jansen, M., et al. Summary of workgroup 2:
Ethical, legal, public policy/advocacy, and professional issues.
Retrieved July 13, 2004, from http://www.appic.org/news/
3_1_news_Competencies.htm.
Glickman, N. (2003). Culturally affirmative inpatient treatment
with psychologically unsophisticated deaf people. In N.
Glickman, & S. Gulati (Eds.), Mental health care of deaf
people: A culturally affirmative approach (pp. 145–202).
Mahwah, NJ: Lawrence Erlbaum.
Gutheil, T., & Gabbard, G. (1993). The concept of boundaries in
clinical practice: Theoretical and risk-management dimen-
sions. American Journal of Psychiatry, 150, 188–196.
Gutman, V. (2002). Ethics in mental health and deafness:
Implications for practitioners in the ‘‘small world.’’ In
V. Gutman (Ed.), Ethics in mental health and deafness
(pp. 11–37). Washington DC: Gallaudet Press.
Downloaded from http://jdsde.oxfordjournals.org/ at University of North Dakota on June 2, 2015
Guthmann, D., & Sandberg, K. (2002). Dual relationships in the
Deaf community. In A. Lazarus, & O. Zur (Eds.), Dual
relationships and psychotherapy. New York: Springer-Verlag.
Haas, L., & Maloof, J. (2002) Keeping up the good work: A
practitioner’s guide to mental health ethics, (3rd ed.). Sarasota,
FL: Professional Resource Exchange.
Harvey, M. (2002). Psychotherapy with deaf and hard of hearing
persons: A systemic model (2nd ed.). Hillsdale, NJ: Lawrence
Erlbaum.
Herlihy, B., & Corey, G. (1996). ACA ethical standards
casebook (5th ed.). Alexandria, VA: American Counseling
Association.
Hill, M., Glaser, K., & Hardin, J. (1995). A feminist model for
ethical decision-making. In E. Rave, & C. Larsen (Eds.),
Ethical decision making in therapy: Feminist perspectives
(pp. 18–37). New York: Guilford Press.
Huber, C. (2001). Ethical, legal, and professional issues in the
practice of marriage and family therapy (3rd ed.). Upper
Saddle River, NJ: Prentice Hall.
International Association of Marriage and Family Counselors
(n.d.) IAMFC ethical standards. Retrieved December 9,
2003, from www.iamfc.com.
Joseph, V., & Conrad, P. (1995). Essential steps for ethical problem-
solving. Retrieved July 13, 2004, from http://courses.cs.
vt.edu/professionalism/Ethics/steps.html.
Kitchener, K. (2000). Foundations of ethical practice, research, and
teaching in psychology. Mahwah, NJ: Lawrence Erlbaum.
Koocher, G., & Keith-Spiegel, P. (1998). Ethics in psychology.
Professional standards and cases (2nd ed.). New York: Oxford
University Press.
Lane, H. (1992). The mask of benevolence: Disabling the deaf
community. New York: Knopf.
Lavin, M. (2003). Thinking well about ethics: Beyond the code.
In W. O’Donohue, & K. Ferguson (Eds.), Handbook of
professional ethics for psychologists (pp. 35–46). Thousand
Oaks, CA: Sage.
Leigh, I. (2002). Ethical problems in deaf mental health services:
A practitioner’s experience. In V. Gutman (Ed.), Ethics in
mental health and deafness (pp. 1–10). Washington DC:
Gallaudet Press.

Leigh, I., & Lewis, J. (1999). Deaf therapists and the Deaf
community: How the twain meet. In Leigh, I. (Ed.),
Psychotherapy with deaf clients from diverse groups
(pp. 45–68). Washington, DC: Gallaudet University Press.
Leigh, I., Corbett, C., Gutman, V., & Morere, D. (1996).
Providing psychological services to deaf individuals: A
response to new perceptions of diversity. Professional
Psychology: Research and Practice, 27, 364–371.
Lytle, L., & Lewis, J. (1996). Deaf therapists, deaf clients, and
the therapeutic relationship. In N. Glickman, & M. Harvey
(Eds.) Culturally affirmative psychotherapy with deaf persons
(pp. 261–276). Mahwah, NJ: Lawrence Erlbaum.
McCrone, W. (2002). Law and ethics in mental health and
deafness. In V. Gutman (Ed.), Ethics in mental health and
deafness (pp. 38–51). Washington DC: Gallaudet Press.
National Association of Social Workers (1996/1999). Code of
ethics of the National Association of Social Workers. Retrieved
December 9, 2003 from www.socialworkers.org.
Peoples, K. (2002). Ethical challenges in training professionals
for mental health services with deaf people. In V. Gutman
(Ed.), Ethics in mental health and deafness (pp. 99–122).
Washington DC: Gallaudet Press.
Pollard, R. (2002). Ethical conduct in research involving
deaf people. In V. Gutman (Ed.) Ethics in mental health
and deafness (pp. 162–178). Washington DC: Gallaudet
University Press.
Raifman, L., & Vernon, M. (1996). Important implications for
psychologists of the Americans with Disabilities Act: Case in
point, the patient who is deaf. Professional Psychology:
Research and Practice, 27, 372–377.
Ethical Reasoning 183
Richards, D. (2003). The central role of informed consent
in ethical treatment and research with children. In W.
O’Donohue, & K. Ferguson (Eds.), Handbook of professional
ethics for psychologists (pp 377–389). Thousand Oaks,
CA: Sage.
Schank, J., Slater, R., Banerjee-Stevens, D., & Skovholt, T.
(2003). Ethics of multiple and overlapping relationships. In
W. O’Donohue, & K. Ferguson (Eds.), Handbook of
professional ethics for psychologist (pp. 181–193). Thousand
Oaks, CA: Sage.
Sussman, A., & Brauer, B. (1999). On being a psychotherapist
with Deaf clients. In I.W. Leigh (Ed.), Psychotherapy with
deaf clients from diverse groups (pp. 3–22). Washington, DC:
Gallaudet University Press.
Thorp, S., & Fruzzetti, A. (2003). Ethical principles and
practice in couple and family therapy. In W. O’Donohue,
& K. Ferguson (Eds.), Handbook of professional ethics for
Downloaded from http://jdsde.oxfordjournals.org/ at University of North Dakota on June 2, 2015
psychologists (pp. 391–405). Thousand Oaks, CA: Sage.
Tugg v Towey (1994). Retrieved July 19, 2004, from
http://www.deaflaw.org/tugg_v.htm.
Welfel, E., & Kitchener, K. (1992). Introduction to the special
section: Ethics education—An agenda for the ’90’s.
Professional Psychology: Research and Practice, 23, 179–181.
Zitter, S. (1996). Report from the front lines: Balancing multiple
roles of a deafness therapist. In N. Glickman, & M. Harvey
(Eds.), Culturally affirmative psychotherapy with deaf persons
(pp. 169–246). Mahwah, NJ: Lawrence Erlbaum.
Received August 21, 2004; revisions received November 24,
2004; accepted November 27, 2004